Provider Demographics
NPI:1700203460
Name:WALLS, TERESA (LPN)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:
Last Name:WALLS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 MAGNOLIA ST
Mailing Address - Street 2:
Mailing Address - City:SUMTER
Mailing Address - State:SC
Mailing Address - Zip Code:29150
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:105 N MAGNOLIA ST
Practice Address - Street 2:SUMTER CO HEALTH DEPT
Practice Address - City:SUMTER
Practice Address - State:SC
Practice Address - Zip Code:29150-4941
Practice Address - Country:US
Practice Address - Phone:803-934-2809
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-03-19
Last Update Date:2014-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC44825PR164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse